Roadblocks to early surgery for patients with cervical spine injury

INTRODUCTION

An acute spinal cord injury (SCI) is a traumatic incident causing sensory, motor, and/or autonomic dysfunctions, ultimately impacting a patient’s physical, psychological, and social well-being. Current concepts of the pathophysiology of acute SCI implicate both primary and secondary mechanisms for neurologic injury. The primary injury, usually caused by rapid spinal cord compression and contusion, initiates a signalling cascade of downstream events collectively known as secondary injury.¹ Surgical decompression aims to interrupt this progression by relieving pressure within the cord parenchyma to partially restore microvascular blood flow and remove mechanical compression on the neuroglial cell membrane. Timely alleviation of this compression may reduce neural tissue injury and improve outcomes. A meta-analysis in 2013, analyzing 21 animal studies, indicated that surgical decompression enhances neurobehavioral outcomes by 35%, with early intervention being a crucial predictor of improvement.²

On the clinical front, various studies have explored the effects of early surgery on neurological, functional, and safety outcomes. However, the lack of consensus on defining “early” versus “late” surgical decompression, with varying time thresholds like 24, 48, and 72 hours, along with discrepancies in adjusting for baseline neurological status, has hindered the development of clear recommendations for the timing of surgical decompression in SCI or central cord syndrome patients. A systematic review by a guideline development group under AO spine for the timing of surgical decompression for central cord syndrome suggested, with low-quality evidence, that early surgery (≤24 hours after injury) as a treatment option for adult patients with central cord syndrome and acute SCI, regardless of the level.³ The results of the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS), a multi-center prospective cohort study, showed improved neurologic outcome, defined as at least a 2-grade American Spinal Injury Association (ASIA) Impairment Scale (AIS) improvement at 6 months follow-up with early (< 24 hours post-injury) versus late (≥24 hours post-injury) surgery post-cervical SCI.⁴

Roadblocks to early surgical decompression can be divided into two groups: a) delay in reaching care, which may include transport facilities from the place of injury, access to a hospital and surgeon providing spine care and; b) delay in receiving care, which may include operating room availability, intensive care resources, multiple diagnostic steps including the initial clinical recognition of SCI and obtaining and interpreting advanced imaging. Therefore, the majority of patients arrive at these centers where all the diagnostic and treatment modalities are available beyond the early decompression window (<24 hours), where timely intervention could translate into potential long-term functional improvement.⁵ Other issues include the financing of surgery, anesthetic clearance, operating room availability, and the high incidence of polytrauma cases requiring interdepartmental cohesion.

Hence, we formulated a spine attack study to make an effort to prioritize traumatic SCI patients with operative indications for early surgical decompression as a quality improvement exercise in the tertiary care hospital, and also evaluate its effect on patient outcomes. This article is the pilot study done to identify the roadblocks for early decompression and aims to determine the time taken for a patient with cervical spine injury from the time of injury to the operating table in a tertiary care setting.

MATERIAL AND METHODS

RESULTS

A total of 20 patients were included in the study, whose demographic details have been detailed in Table 1. The mean referral distance for all cases was calculated based on the distance from the referral center to our tertiary care center on Google Maps, with a calculated mean of 157.2 ± 86.13 km. In addition, we noted the times taken from injury to presentation and surgery, and means were calculated for these. These have been reported in Table 2, with a mean time of injury to surgery in our study cohort being 156.85 ± 92.4 hours.

The reasons for the delay in the operation theatre were noted in all cases. None of the cases were operated on within 24 hours of injury or 24 hours of presentation to the hospital. We noted the causes of delay in surgical management after the patients reported to the trauma center. There was significant overlap amongst cases, with more than one reason being ascribed to multiple patients. The most common of these were the non-availability of a slot in the operation theatre (65%) and the non-availability of intensive care backup post-surgery (40%). All of these are summarized in Table 3. In individuals who were considered unfit for surgery (35%), the most common reasons were pulmonary complications and other associated injuries, including pelvis and lower limb injuries, in 20% of the patients included. 15% of patients came from a very poor background, and funds had to be arranged before taking them up for surgery to procure the consumables and the implants. None of the comorbidities mentioned was responsible for the delay in the surgery.

DISCUSSION

In this observational study, we determined the demographic profile of patients with cervical SCI presenting to an apex tertiary care center in North India and identified potential roadblocks to adequate management in these cases. The demographic profile in our study cohort was similar to what has previously been reported in SCI from the same region and worldwide.^6-8 Though there is literature regarding the assessment of the barriers to early surgery,⁹ emanating from western world where the socio-demographic conditions are different from Southeast Asia, and assessment of the roadblocks in this region is of particular importance as it is a vast majority of population which resides in this region with unique socio-demographic profile. With this pilot study, we intend to collaborate with other centers in this part of the world to generate high-quality evidence for an evidence-based approach to optimize patient outcomes.

While clinical guidelines have established that early surgery and stabilization must be the standard of care in acutely injured individuals with SCI, multiple barriers have been identified in the literature that make achieving this target a challenge to spine surgeons. The most common among these include lack of operating room availability, delayed transfers to a center equipped to handle such cases, and intensive care unavailability.^10,11 In an analysis conducted using data from the Rick Hansen Spinal Cord Registry (RHSCIR), Glennie et al.¹¹ (2017) determined that only 39% of cervical SCI were operated on within 24 hours of injury. In their study cohort, 80% of individuals were transferred to the referral center within 24 hours of injury, in contrast to our findings, where only 45% of cases reached our center within the first 24 hours.¹¹ Furlan et al.¹² (2013) identified healthcare-related factors (extrinsic), like referral distance and time taken to reach the hospital, and patient-related factors (extrinsic) like associated injuries and comorbidities, and determined that extrinsic factors had a greater role to play in the delay in the surgical management of patients with SCI.¹²

We conducted this pilot study to identify the roadblocks to early surgical care for patients with acute SCI. Along with factors discussed in studies from Western literature, some factors were unique to our setting. These include factors such as patient consent due to unwillingness for surgery, cultural taboos, and, more importantly, the financial constraints of the patients presenting with these injuries.⁷ An unorganized referral system is another significant deterrent to early decompression. Long-term goals should include a timely referral system and the establishment of institutional and nationwide protocols to streamline patient management for early intervention and to optimize outcomes.

CONCLUSION

Early surgical decompression has been shown to improve neurological and functional outcomes in patients with cervical SCI; however, achieving this standard remains a challenge in tertiary care settings. Our pilot study highlights multiple roadblocks chiefly delays in presentation, unavailability of operating room and intensive care facilities, anaesthetic clearance issues, and financial constraints that collectively push surgery well beyond the recommended early intervention window. Addressing these barriers through streamlined referral systems, priority operating room protocols, dedicated intensive care resources, and financial support mechanisms is essential. A coordinated, multidisciplinary approach and institutional reforms are necessary to bridge the gap between evidence and practice, ultimately improving outcomes for patients with traumatic cervical spine injury.